Well, we did it. The United States has reached a critical mass of children developing type 2 diabetes. One out of three children diagnosed with diabetes today are diagnosed with type 2. That’s a very scary statistic. It’s what drove the American Academy of Pediatricians (AAP) to issue its first ever guidelines for the treatment of type 2 diabetes in children, to help pediatricians who are not endocrinologists become more familiar with the needs of this growing patient population.
The recommendations cover a wide scope of topics from lifestyle modification to medication choice and monitoring guidelines. Six major topics are covered.
Insulin becomes the drug of choice for type 2 patients in certain cases. The committee recommends that clinicians should start insulin in any patient whom they cannot initially differentiate between having type 1 or type 2 diabetes. Insulin should also be used in cases where patients are ketotic, (evidence of specialized fat cells and deficiency of insulin in the blood) have random venous or plasma blood glucose concentrations ≥250mg/dL or have an A1C is >9 percent.
Presentation of type 2 diabetes in children and adolescents can be a bit different than in adult patients, and may be confused with type 1. This happens because children with type 2 can present in ketoacidosis (a life-threatening condition brought on by the lack of insulin) and develop glucose toxicity (high blood glucose can cause the beta cells to fail and promote insulin resistance.) Due to the obesity epidemic, children with type 1 diabetes are, also, increasingly presenting with obesity.
For those not meeting the above criteria, the guidelines recommends that healthcare providers prescribe metformin, (a drug which reduces glucose output from the liver) and lifestyle modification including dietary and exercise changes.
To ensure that the prescribed treatment is effective, monitoring of A1Cs should occur in the physician’s office every three months. Although blood glucose targets are generally higher in children than in adults, based on the evidence, the APA has set an A1C of 7 percent as a population goal. It emphasizes that goals should always be individualized based on each patient’s unique situation.
In addition to using the A1C to monitor metabolic control, the recommendations include using self-monitoring of blood glucose (SMBG) for those on insulin, those who haven’t met treatment goals and for those who are experiencing another illness, such as the flu, simultaneously. The frequency of monitoring is determined by the medication regimen and the patient’s level of control, although initially all patients are encouraged to monitor before meals and at bedtime.
The guidelines recommend that nutrition therapy follow the guidelines set out in Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines and are ongoing through the patient’s life.
The recommendation for exercise is a hefty one and harkens back to the days of mandatory gym classes in school. The guidelines recommend children spend at least 60 minutes a day in moderate to vigorous, daily exercise, and limit non-academic TV and computer time to less than two hours a day.